List I - Core Conditions Flashcards
1
Q
What is acne?
A
- Acne vulgaris is a chronic inflammatory skin condition affecting mainly the face (99% of cases), back (60% of cases) and chest (15% of cases)
2
Q
What are the pathological features of acne vulagiris?
A
- Characterised by blockage and inflammation of the pilosebaceous unit (the hair follicle, hair shaft and sebaceous gland)
- Presents with lesions that can be non-inflammatory, inflammatory or a mixture of both
- Non-inflammed lesions are known as comedones which may be open (blackheads), closed (whiteheads) or microcomedones (clinically invisible)
- Inflammatory acne lesions include papules and pustules (5 mm or less in diameter) - in more severe disease these can develop into larger deeper pustules and nodules
- Most people with acne have a mixture of inflammatory and non-inflammatory lesions
3
Q
What is mild acne?
A
- Predominantly non-inflammed lesions (open and closed comedones) with few inflammatory lesions
4
Q
What is moderate acne?
A
- More widespread with an increased number of inflammatory papules and pustules
5
Q
What is severe acne?
A
- Widespread inflammatory papules, pustules and nodules or cysts, scarring may be present
6
Q
What is conglobate acne?
A
- A rare and severe form of acne found most often in men - presents with extensive inflammatory papules, suppurative nodules (which may coalesce to form sinuses) and cysts on the trunk and upper limbs
7
Q
What is acne fulminans?
A
- Sudden severe inflammatory reaction that precipitates deep ulcerations and erosions sometimes with systemic effects (fever and arthralgia)
8
Q
What is thought to cause acne?
A
- Not completely understood but thought thought to involve:
- Altered follicular keratinocyte proliferation leading to formation of follicular plugs (comedones)
- Androgen induced seborrhoea (increased sebum production) within the sebaceous follicles which usually occurs around puberty
- Proliferation of bacteria (such as propionibacterium acnes) within sebum in hair follicles
- Inflammation of the pilosebaceous unit
Other factors include:
- Genetic
- Racial and ethnic
- Diet
9
Q
How common is acne?
A
- Estimated 650 million worldwide
- Up to 95% of adolescents in Western industrialised countries are affected to some extent
- Distribution of people with acne:
- 85% aged 12-24 years
- 8% aged 25-34 years
- 3% aged 35-44 years
- More common in males during adolescence but in adulthood, incidence is higher in women
10
Q
What are the complications of acne vulagiris?
A
- Skin changes
- Scarring - acne may result in hypertrophic or atrophic scars which can be extensive
- Post inflammatory hyperpigmentation or depigmentation can occur
- Psychosocial effects
- Acne is associated with significant psychological problems including an increased risk of depression, suicide, anxiety, reduced attachment to friends and low self esteem
11
Q
What is the prognosis of acne vulgaris?
A
- Chronic disease that can persist for many years - tends to affect adolescents and usually resolves after the end of growth
- May persist into adulthood as a continuation of adolescence acne
- Predictive factors for persistence into adulthood for females is less clear
12
Q
What are the clinical features of acne vulgaris?
A
- Acne affects areas of the body with a high density of pilosebaceous glands such as the face, chest and back
- Clinical features vary widely depending on severity and the person affected
- Comedones must be present for a diagnosis of acne to be made if not present other diagnoses should be considered
- Suspect acne in a person presenting with:
- Non-inflammed lesions (comedones) which may be open (blackheads) or closed (whiteheads)
- Inflammatory lesions such as:
- Papules and pustules - superficial raised lesions (less than 5 mm in diameter)
- Nodules or cysts (larger than 5 mm in diameter) - deeper, palpable lesions which are often painful and may be fluctuant - very severe acne nodules may track together and form sinuses (acne conglobata)
- Scarring - atopic/ice pick or hypertrophic/keloid scars may be seen
- Pigmentation - post inflammatory depigmentation or hyperpigmentation may be present
- Seborrhoea - commonly present
13
Q
How should a history of a person with acne vulgaris be taken?
A
Ask about the following:
- Duration, type and distribution of lesions.
- Previous treatment (including over-the-counter medications) and response.
- Exacerbating factors such as flares with menstruation, contraceptives, cosmetics, face creams or hair pomades.
- Systemic features — some rare subtypes of acne (acne fulminans) can present with systemic features including fever, arthralgia, and myalgia.
- Psychosocial impact of acne — ask about psychological problems including anxiety and low mood.
- Family history including endocrine disorders, polycystic ovarian syndrome, acne and other skin conditions.
- Possible underlying causes:
- Drug history — some medications can cause or exacerbate acneform rashes including androgens, corticosteroids, isoniazid, ciclosporin and lithium.
- Hyperandrogenism — may present with irregular periods, androgenic alopecia or hirsutism in women
14
Q
What are the differential diagnoses of acne vulgaris?
A
- Rosacea
- Perioral dermatitis
- Folliculitis and boils
- Drug induced acne
- Dioxins (chloracne), corticosteroids, anti-epileptics (phenytoin and carbamazepine), lithium, isoniazid, vitamins B1, B6, and B12
- Keratosis pilaris
15
Q
What is the advice for initial conservative and management for the maintenance of healthy skin for people with acne vulgaris?
A
- Discuss treatment aims
- Advise to avoid over cleaning the skin (can cause dryness and irritation, acne is not caused by poor hygiene and twice daily washing with a gentle soap and fragrance-free cleanser is adequate
- If make up, cleansers and/or emollients are used, non-comedogenic preparations with a pH close to the skin are recommended
- Avoid picking and squeezing spots which may increase the risk of scarring
- Advise that treatments are effective but take time to work (usually up to 8 weeks) and may irritate the skin, especially at the start of treatment
- Maintain a healthy diet
16
Q
What is the management advice to people with mild to moderate acne vulgaris?
A
- Consider prescribing a single topical treatment such as:
- Topical retinoid (e.g. adapalene alone or in combination with benzyl peroxide NB retinoids are contraindicated in pregnancy and breast feeding
- Topical antibiotic (e.g. clindamycin 1%) - antibiotics should always be prescribed in combination with benzoyl peroxide to prevent development of bacterial resistance - topical benzoyl peroxide and erythromycin are usually considered to be safe in pregnancy
- Azelaic acid 20%
- Creams and lotions may be preferable for people with dry or sensitive skin and less greasy gels may be preferable for people with oily skin
- Concentration or application frequency of topical treatments may need to be reduced or lowered if skin irritation occurs
17
Q
What is the management advice to people with moderate acne vulgaris not responding to topical treatment?
A
- If response to topical preparations alone is inadequate consider adding an oral antibiotic, a tetracycline such as lymecycline or doxycycline (for a maximum of 3 months)
- Topical retinoid or benzoyl peroxide should always be prescribed with oral antibiotics to reduce the risk of resistance developing
- Macrolides such as erythromycin should generally be avoided due to high levels of P.acnes resistance but can be used if tetracyclines are contraindicated e.g. pregnancy
- Change to an alternative antibiotic if there is no improvement after 3 months
- Refer to dermatology if not responding to two different courses of antibiotics or if they are starting to scar
18
Q
What is the advice regarding combined oral contraceptives with acne vulgaris?
A
- COCP in combination with topical agents can be considered as an alternative to systemic antibiotics in women
- Oral progesterone only contraceptives or progestin implants with androgenic activity may exacerbate acne, 3rd and 4th generation COCP are preferred
- Co-cyprindiol (Dianette) or other ethinylestradiol/cyproterone acetate containing products may be considered in moderate to severe acne where other treatments have failed but require careful discussion of the risks and benefits with the patient
- Use should be discontinued 3 months after acne has been controlled and prescription guided by the UK Medical Eligibility Criteria
19
Q
When should a person with acne be referred to dermatology?
A
- Severe variant of acne such as acne conglobata or acne fulminans (immediate referral)
- Severe acne associated with visible scarring or are at risk of scarring or significant hyperpigmentation - primary care treatment should be initiated in the interim
- Multiple treatments in primary care have failed
- Significant psychological distress is associated with acne regardless of severity
- Diagnostic uncertainty
20
Q
When should follow up for acne treatment/management be arranged?
A
- Review each treatment step at 8-12 weeks
- If adequate response continue treatment for at least 12 weeks
- If acne has cleared or almost cleared - consider maintenance therapy with topical retinoids (first line) or azelaic acid
- If no response, check for adherence, adverse effects, progression to more severe acne, or use of comedogenic make up or face creams
21
Q
How should benzoyl peroxide be prescribed for acne vulgaris?
A
- For Child 12–17 years — apply to the skin 1–2 times a day, preferably after washing with soap and water and start treatment with lower-strength preparations.
- For Adult — apply to the skin 1–2 times a day, preferably after washing with soap and water, and start treatment with lower-strength preparations
22
Q
What are the cautions and contraindications for prescribing benzoyl peroxide?
A
- Hypersensitivity to the active substance or to any of the excipients.
- Avoid contact with broken skin, eyes, mouth and mucous membranes
23
Q
What are the adverse effects of benzoyl peroxide treatment?
A
- Skin irritation (dryness, discomfort, erythema, peeling and blistering) — reduce frequency or stop use until irritation settles then re-introduce at reduced concentration or frequency.
- Allergic contact dermatitis to benzoyl peroxide occurs in 1 in 500 people — consider if itching and swelling of the eyes occurs.
- Increased risk of sunburn — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used.
- May bleach fabrics and hair
24
Q
What is the indication for topical retinoids for the treatment of acne vulgaris?
A
- Adapalene and tretinoin are the topical retinoids licenced for use in children over the age of 12 and adults in the UK.
- Topical isotretinoin is licenced for use in adults only
- If peeling due to use of other irritant acne treatments is present, allow to subside before starting a topical retinoid — discontinue use if severe irritation occurs.
- Topical retinoids should be used sparingly to cover the whole affected area and not just on visible spots — if the person has sensitive skin, initiate therapy at a lower frequency (for example three times per week) and increase to daily use as tolerated.
- Concomitant use of a noncomedogenic moisturizer and sunscreen may also help tolerability
25
Q
What are the contraindications to the use of topical retinoids for the treatment of mild to moderate acne vulgaris?
A
- Hypersensitivity to the active substance or to any of the excipients.
- Avoid in pregnancy and breastfeeding — women of child-bearing age must use effective contraception.
- Avoid in people with severe acne, perioral dermatitis, rosacea or a personal or family history of non-melanoma skin cancer.
- Avoid accumulation in angles of the nose and contact with eyes, nostrils, mouth and mucous membranes, eczematous, broken or sunburned skin.
- Avoid exposure to excess UV light (including sunlight and solariums) — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used
26
Q
What are the adverse affects of using topical retinoids for the acne?
A
- Skin irritation including discomfort, blistering of skin, burning, crusting, dryness, peeling, erythema, oedema, pruritus, stinging, contact dermatitis and temporary changes of skin pigmentation.
- Eye irritation.
- Increased sensitivity to UV light — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used
27
Q
Which topical antibiotics can be prescribed for acne vulgaris?
A
- Clindamycin
- Erythromycin
Should be prescribed in combination with benzoyl peroxide - monotherapy not recommended
28
Q
How should azelaic acid be prescribed for acne vulgaris?
A
- For Child 12–17 years — apply twice daily. In people with sensitive skin, apply once daily for 1 week, then apply twice daily.
- For Adult — apply twice daily. In people with sensitive skin, apply once daily for 1 week, then apply twice daily.
- If skin irritation occurs reduce the amount used or frequency of application to once a day until the irritation ceases — temporarily interrupt treatment for a few days if required
29
Q
When should oral antibiotics be prescribed for acne vulgaris?
A
- If acne fails to respond adequately to topical preparations alone an oral antibiotic such as lymecycline or doxycycline (for a maximum of 3 months) can be added
30
Q
What is acne rosacea?
A
- Chronic inflammatory skin condition predominantly affecting the convexities of the centrofacial region (cheeks, chin, nose, and central part of the forehead)
31
Q
What are the clinical features of acne rosacea?
A
- Typically affects nose, cheeks, and forehead
- Flushing is often first symptom
- Telangiectasia are common
- Later develops into persistent erythema with papules and pustules
- Rhinophyma
- Ocular involvement - blepharitis
- Sunlight may exacerbate symptoms
32
Q
What are the management options of acne rosacea?
A
- Topical metronidazole may be used for mild symptoms i.e. limited number of papules and pustules, no plaques
- Topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia
- More severe disease is treated with systemic antibiotics e.g. oxytetracycline
- Recommended daily application of a high factor sunscreen
- Camoflage creams may help conceal redness
- Laser therapy may be appropriate for patients with prominent telangiectasia
- Patients with a rhinophyma should be referred to dermatology
33
Q
What is eczema?
A
- Atopic eczema (also known as atopic dermatitis) is a chronic, itchy, inflammatory skin condition that affects people of all ages, although it presents most frequently in childhood
- Typically an episodic disease of flares and remissions, in severe cases disease activity may be continuous
34
Q
What is the cause of eczema?
A
- Complex condition involving genetic, immunological and environmental factors, leading to a dysfunctional skin barrier and immune system dysregulation
- Recent evidence suggests that mutatitions in the filaggrin gene is a likely cause for almost 50% of cases of atopic eczema - filaggrin gene is essential for the conversion of keratinocytes to the protein/lipid squames that make up the outermost barrier layer of the skin (stratum corneum) - defect in filaggrin causes skin barrier dysfunction
- Primary function of the skin barrier is to restrict water loss and to prevent entry of irritants, allergens, and skin pathogens
35
Q
What is the pathogenesis of eczema as a result of filaggrin gene dysfunction?
A
- Leads to water loss from the skin, leading to dryness and itching
- Makes the skin susceptible to allergens, leading to hyperreactive and induction of immunoglobulin E (IgE) autoantibodies
- Predisposes the skin to colonisation or infection by microbes, such as staphylococcus aureus
36
Q
What are the factors thought to trigger atopic eczema?
A
- Soap and detergent, animal dander, house-dust mites, extreme temperatures, rough clotting, pollen, certain foods and stress
37
Q
How common is eczema?
A
- Common and prevalence is increasing
- Affects 10-30% of children
- 2-10% of adults
38
Q
What are the complications of eczema?
A
- Infection
- Bacterial infection with stapylococcus aureus may present as typical impetigo or as worsening of eczema (with increased redness, oozing and crusting of the skin)
- Herpes simplex infection indicated by punched out erosions may occur
- Disseminated herpes simplex virus infection (eczema herpeticum) presents with widespread lesions that may coalesce into large, denuded, bleeding areas that can extend over the entire body, occasionally complicated by secondary infection with staphylococcal or streptococcal species
- Fever, lymphadenopathy and malaise are common with eczema herpetiform - medical emergency in children under the age of 2 years
- Psychosocial problems
- Distress and depression
- Preschool children have higher rates of behaviour problems and problems with poor self image and self confidence that can impair social development
- Sleep disturbance is a major problem in atopic eczema and their families
39
Q
What is the prognosis of patients with eczema?
A
- Atopic eczema typically is episodic with flares of disease (two or three times per month) and remissions
- Atopic eczema has a tendency to gradual improvement in adult life
- Condition is expected to clear in about 65% of children by the time they are 7 years of age an in about 74% of children by the age of 16 years
- Many children with atopic eczema will go on to develop asthma (30-50%) and/or hay fever (30-80%)
40
Q
What questions should be asked in taking a history of eczema?
A
- Presence of itching - if no itch then atopic eczema is unlikely
- Pattern, time of onset and natural history of the rash - atopic eczema usually starts in infancy and is episodic in nature
- Family or personal history of atopy - allergic rhinitis and asthma are associated with atopic eczema
- Treatments tried and response
- Possible triggers (irritant or allergic)
41
Q
What should you look for on examination of a person with suspected eczema?
A
- In adults - generalised dryness and itching particularly with exposure to irritants - on the hands may be the primary manifestation
- in children and adults with long standing disease - eczema is often located on the flexure of the limbs
- In infants - eczema primarily involves the face, the scalp, and the extensor surfaces of the limbs - nappy area spared
- Acute eczema - varies in appearance from poorly demarcated redness to fluid in the skin (vesicles), scaling or crusting of the skin
- Chronic eczema - characterised by thickened (lichenified) skin resulting from repeated scratching
- If eczema is weeping, crusted or there are pustules with fever or malaise secondary bacterial infection should be considered
42
Q
What are the NICE criteria for making a diagnosis of eczema?
A
- An itchy skin condition (or parental report of scratching) plus 3 or more of the following:
- Visible flexural eczema involving the skin creases, such as the bends of the elbows or behind the knees (or visible eczema on the cheeks and/or extensor areas in children aged 18 months or younger)
- Personal history of flexural eczema (or eczema on the cheeks and/or extensor areas in children aged 18 months or younger)
- Personal history of dry skin in the last 12 months
- Personal history of asthma or allergic rhinitis (or history of atopic disease in a first degree relative of a child aged under 4 years
- Onset of signs and symptoms before the age of 2 years (this criterion should not be used in children younger than 4 years of age)
NB these criteria apply to all ages, social classes, and ethnic groups. However, in children of Asian, black Caribbean, and black African ethnic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid or follicular patterns may be more common.
43
Q
What are the potential trigger factors to ask about in a person suspected of having eczema?
A
- Irritant allergens
- Irritant clothing
- Skin infections
- Contact allergens
- Inhaled allergens
- Hormonal triggers
- Climate
- Concurrent illness and disruption to family life
- Dietary factors
44
Q
What are the differential diagnoses for eczema?
A
- Psoriasis
- Allergic contact dermatitis
- Seborrhoeic dermatitis
- Fungal infection
- Scabies or other infestations
45
Q
How is treatment of eczema guided?
A
- At each consultation assess the severity of the eczema in order to determine the most appropriate treatment
- At each consultation assess the psychological impact of atopic eczema
46
Q
How is the severity of the eczema determined?
A
- Examine all areas of affected skin and ask about itching
- Clear - normal skin, no evidence of active eczema
- Mild - areas of dry skin and infrequent itching (with or without small areas of redness)
- Moderate - areas of dry skin, frequent itching and redness (with or without excoriation and localised skin thickening)
- Severe - widespread areas of dry skin, incessant itching and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation
- Infected - eczema is weeping, crusted or there are pustules with fever or malaise
47
Q
What can be used to assess the patients severity of eczema?
A
- Validated tools such as a visual analogue scale (0-10) of the person’s assessment of severity, itch, and sleep loss over the last 3 days and nights or the Patient-Oriented Eczema Measure
48
Q
How is the psychological impact of atopic eczema measured?
A
- Ask about the effect of eczema on daily activities (school, work and social life) , sleep and mood
- Categorised the impact on quality of life and psychosocial well being as:
None - no impact
Mild - little impact on everyday activities, sleep and psychosocial well being
Moderate - moderate impact on everyday activities and psychosocial well being and frequently disturbed sleep
Severe - severe limitation of everyday activities and psychosocial functioning and loss of sleep every night
49
Q
What can be used to assess the patients psychological impact of eczema?
A
- Consider using questionnaires to give an objective measure of quality of life
- Children’s / Adult’s Dermatology Life Quality Index
50
Q
What is the management for mild eczema?
A
- Prescribe generous amounts of emollients, and advise frequent and liberal use.
- Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled
51
Q
What is the management for moderate eczema?
A
- Prescribe a generous amount of emollients, and advise frequent and liberal use (more than usual)
- If the skin is inflamed, prescribe a moderately potent topical corticosteroid (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%) to be used on inflamed areas. Treatment should be continued for 48 hours after the flare has been controlled
- For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%) and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days’ use
- Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae)
52
Q
What is the management for severe eczema?
A
- Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual)
- If the skin is inflamed, prescribe a potent topical corticosteroid (for example betamethasone valerate 0.1%) to be used on inflamed areas
- For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%). Aim for a maximum of 5 days’ use
- Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae)
53
Q
How should infected eczema be managed?
A
- Flucloxacillin is the first-line choice.
- Prescribe erythromycin if the person has an allergy to penicillin or if there is known resistance to flucloxacillin. If the person has previously been unable to tolerate erythromycin because of nausea or cramps, consider prescribing clarithromycin
54
Q
What is the principle regarding topical steroid treatment for eczema?
A
- Use the weakest steroid cream which controls the patients symptoms
55
Q
What is a mild potency topical steroid?
A
- Hydrocortisone
0. 5-2.5%
56
Q
What is a moderate potency topical steroid?
A
- Betamethasone valerate 0.025% (Betnovate RD)
* Clobetasone butyrate 0.05% (Eumovate)
57
Q
What is a potent topical steroid?
A
- Fluticasone propionate 0.05% (Cutivate)
* Betamethasone valerate 0.1% (Betnovate)
58
Q
What is a very potent topical steroid?
A
- Clobetasol propionate 0.05% (Dermovate)
59
Q
What is the guidance to patients in terms of sufficient amounts of emolient/topical steroids to use?
A
- Finger tip rule
- 1 finger tip unit (FTU) = 0.5 g sufficient to treat a skin area about twice that of the flat of an adult hand
60
Q
What finger tip dose of topical steroid for an adult is required to cover the hand and fingers (front and back)?
A
- 1.0
61
Q
What finger tip dose of topical steroid for an adult is required to cover a foot (all over) ?
A
- 2.0
62
Q
What finger tip dose of topical steroid for an adult is required to cover the front of chest and abdomen?
A
- 7.0
